CLINICAL PRACTICE GUIDELINES MANAGEMENT OF IMMUNE THROMBOCYTOPENIC

CLINICAL PRACTICE GUIDELINES MANAGEMENT OF IMMUNE THROMBOCYTOPENIC

CLINICAL PRACTICE GUIDELINES
August 2006
MOH/P/PAK/115.06 (GU)
MANAGEMENT
OF
IMMUNE THROMBOCYTOPENIC
PURPURA
BE R
S A TU
I•
AKT
•BERUSAHA•BERB
MINISTRY OF HEALTH MALAYSIA
ACADEMY OF MEDICINE
Statement of Intent
This clinical practice guideline is meant to be a guide for clinical
practice, based on the best available evidence at the time of
development. Adherence to these guidelines may not necessarily
ensure the best outcome in every case. Every health care provider
is responsible for the management of his/her unique patient based
on the clinical picture presented by the patient and the management
options available locally.
Review of the Guidelines
This guideline was issued in August 2006 and will be reviewed in
August 2008 or sooner if new evidence becomes available.
CPG Secretariat
c/o Health Technology Assessment Unit
Medical Development Division
Ministry of Health Malaysia
Level 4, Block E1, Parcel E,
Government Office Complex,
62590, Putrajaya.
Available on the following website :
http//www.moh.gov.my
http://www.acadmed.org.my
GUIDELINES DEVELOPMENT AND OBJECTIVES
Guideline Development
The development group for this guideline comprised of paediatricians,
physicians, haematologists and an obstetrician from the Ministry of Health
Malaysia and Ministry of Education.
The evidence search was carried out using Pubmed, Ovid and general
search engines with ‘idiopathic thrombocytopenic purpura’; ‘immune
thrombocytopenic purpura’; ‘platelet count’; autoimmune thrombocytopenic
purpura’; ‘refractory thrombocytopenic purpura’; ITP; thrombocytopenia AND
therapy as the key words. For paediatric AND pregnancy articles the previous
search terms were combined with ‘child’ and ‘children’ and pregnancy
respectively. The search excluded secondary causes of ITP e.g. ‘drug
induced thrombocytopenia’; ‘secondary immune thrombocytopenia’.
“Related articles were selected and out of these, relevant articles were
chosen and graded using the modified version of those used by the Catalonia
Agency for Health Technology Assessment (CAHTA) Spain.
This guideline was also adapted from other international guidelines on
Management of Idiopathic Thrombocytopenic Purpura which include
Guidelines for the Investigation and Management of Idiopathic
Thrombocytopenic Purpura in Adults, Children and in Pregnancy by British
Society for Haematology and Idiopathic Thrombocytopenic Purpura: A
practice guideline by American Society of Haematology. This guideline is
also based on the findings of a systematic review of current medical
literature, taking into consideration local practices. The draft guideline was
posted on both the Ministry of Health Malaysia and Academy of Medicine,
Malaysia websites for comment and feedback. This guideline has also been
presented to the Technical Advisory Committee for Clinical Practice
Guidelines and the Health Technology Assessment and Clinical Practice
Guidelines Council, Ministry of Health Malaysia for review and approval.
A systematic approach to the treatment modalities was suggested depending
on the conditions associated with ITP. This is summarised as an algorithm
of management of ITP in adults, children and pregnancy.
i
Objectives
The main aim of the guideline is to enable practitioners to make informed
evidence based decisions on the diagnosis and management of Immune
Thrombocytopenic Purpura (primary or idiopathic).
Clinical Questions
The clinical questions of this guideline are:
i)
What is the clinical spectrum of Immune Thrombocytopenic Purpura?
ii)
How is Immune Thrombocytopenic Purpura diagnosed?
iii)
How can patients with Immune Thrombocytopenic Purpura be treated
optimally?
Target Population
This guideline is developed for the management of patients with Immune
Thrombocytopenic Purpura in children, adults and pregnant mothers.
Target Group
This guideline is applicable to all primary care providers, physicians,
paediatricians, obstetricians and others involved in treating patients with
Immune Thrombocytopenic Purpura.
ii
GUIDELINE DEVELOPMENT GROUP
CHAIRPERSON
Dr. Jameela Sathar
Consultant Haematologist
Hospital Ampang
Selangor
MEMBERS
Dr.Soo Thian Lian
Consultant Paediatrician
Hospital Queen Elizabeth
Sabah
Dr. Sinari Salleh
Consultant Haematologist
Hospital Sultanah Aminah
Johor Bahru, Johor
Dr. Goh Ai Sim
Consultant Haematologist
Hospital Pulau Pinang
Pulau Pinang
Dr. Mahfuzah Mohamed
Paediatric Haemato-Oncologist
Paediatric Institute
Hospital Kuala Lumpur
Dr. Ong Swee Gaik
Consultant Rheumatalogist
Hospital Selayang
Selangor
Dr Eeson Sinthamoney
Obstetrician and Gynaecologist
Hospital Ampang
Selangor
Dr Ho Lee Ming
Physician
Hospital Pakar Sultanah Fatimah
Muar, Johor
Assoc Professor Hany Ariffin
Consultant Paediatrician
University Malaya Medical Centre
Kuala Lumpur
COORDINATORS
Dr Sheamini Sivasampu
Principal Assistant Director
Health Technology Assessment Unit
Medical Development Division
Ministry of Health Malaysia
Dr S Sivalal
Deputy Director
Health Technology Assessment Unit
Medical Development Division
Ministry of Health Malaysia
Mr. Ganesan a/l Thankaveloo
Senior Medical Assistant
Health Technology Assessment Unit
Medical Development Division
Ministry of Health Malaysia
iii
SPECIALIST REVIEWERS (in alphabetical order)
The draft guideline was reviewed by a panel of independent expert referees,
who were asked to comment primarily on the comprehensiveness and accuracy
of interpretation of the evidence supporting the recommendations in the guideline.
Professor Abdul Rahman Jamal
Senior Consultant Paediatric Haematologist-Oncologist
Hospital Universiti Kebangsaan Malaysia
Dr Lin Hai Peng
Senior Consultant Paediatric Haematologist-Oncologist
Subang Jaya Medical Centre
Selangor
Dr Chang Kian Meng
Head of Department and Consultant Haematologist
Department of Hematology
Hospital Kuala Lumpur
Dr Mukundan Krishnan
Head of Department and Senior Consultant Obstretic And Gynaecologist
Department Obstretic & Gynaecology
Hospital Ipoh
Dr Ng Siew Hian
Head of Department and Senior Consultant Anaesthesiologist
Department of Anaesthesiology
Hospital Kuala Lumpur
Dr V Purushothaman
Senior Consultant Haematologist
Hospital Kuala Lumpur
Dr Raman Subramaniam
Senior Consultant Obstretic And Gynaecologist
Fetal Medicine & Gynaecology Centre
Kuala Lumpur
iv
TABLE OF CONTENTS
Guideline Development And Objectives
Clinical Practice Guidelines Development Group
Specialist Reviewers
i
iii
iv
1.
INTRODUCTION
1
2.
ITP IN ADULTS
1
2.1
Clinical Features
1
2.2
Diagnosis
a.
Clinical
b.
Laboratory
1
1
3
2.3
Management of Chronic ITP
4
a.
First Line Treatment
i.
Corticosteroids
ii.
Intravenous Immunoglobulin
4
4
5
b.
Second Line Treatment
i.
Splenectomy
Predicting response to splenectomy
Post operative complications
Accessory spleen
ii.
Danazol
iii.
Azathioprine
iv.
Dapsone
v.
Anti-D7
5
5
6
6
6
7
7
7
c.
Treatment Refractory ITP
i.
Eradication of Helicobacter Pylori
ii.
Intravenous Immunoglobulin
iii.
Vinca Alkaloids
iv.
High Dose Methylprednisolone
v.
Cyclosporin A
vi.
Mycophenolate Mofetil
vii.
Anti-CD20 antibody (Rituximab)
viii. Combination therapy
ix.
Others
8
8
8
8
8
8
9
9
9
9
d.
Emergency Treatment
9
v
3.
4.
ITP IN CHILDREN
11
3.1
3.2
3.3
3.4
12
13
14
14
Management of Acute ITP
Management of Chronic ITP
Refractory ITP
Emergency Treatment
ITP IN PREGNANCY
16
4.1
16
16
16
17
18
19
20
4.2
Diagnosis
a.
Clinical
b.
Laboratory
Management
a.
Management before 36 weeks
b.
Management after 36 weeks
c.
Management in labour
5
NEONATAL CARE
6.
ALGORITHM
6.1
6.2
6.3
7.
21
Treatment Algorithm : ITP in Adults
Treatment Algorithm : ITP in Children
Treatment Algorithm : ITP in Pregnancy
22
23
24
REFERENCES
25
ACKNOWLEDGEMENTS
DISCLOSURE STATEMENT
SOURCES OF FUNDING
34
34
34
vi
1.
INTRODUCTION
Immune thrombocytopenic purpura (ITP) affects both children and adults. It
is an autoimmune disorder characterised by persistent thrombocytopenia
(peripheral platelet count of less than 150 x109/L) due to autoantibody binding
to platelet antigen(s) causing their premature destruction by the reticuloendothelial system, in particular the spleen.
In childhood, the peak age is 2-4 years, girls and boys are equally affected,
and in most children the disease is self-limiting with spontaneous recovery
occurring in several weeks to several months. In adults, ITP is most common
among young women and the disease is more insidious in its onset and
chronic in its course 1 Level 9. The true incidence of ITP is still unknown. In
children, the overall incidence of ITP is 4 – 5.3 per 100,000 2 Level 8 ; 3 Level 6. It
has been reported that the incidence of chronic adult ITP is around 5.8-6.6
new cases per 100,000 population per year in the USA 4 Level 9.
2.
ITP IN ADULTS
2.1 Clinical Features
In adults, ITP typically has an insidious onset, with no prodromal illness.
Symptoms and signs are highly variable, ranging from the common
asymptomatic patient with mild bruising or mucosal bleeding to frank
haemorrhage from any site, the most serious of which is intracranial.
The most common manifestation in ITP is mucocutaneous bleeding with
purpura, epistaxis, gingival bleeding and menorrhagia. Overall, bleeding
symptoms are uncommon unless the ITP is severe (platelet count < 30x109/
l) 1 Level 9. The degree of bleeding is largely dependent on the platelet count
and patients with platelet counts below 10x109/l (and usually below 5x109/l)
are at greatest risk of bleeding, including intracranial haemorrhage.
2.2 Diagnosis
There is no gold standard diagnostic test to confirm ITP. The diagnosis of
ITP remains clinical and is based principally on the exclusion of other causes
of thrombocytopenia by the history, physical examination, full blood count,
peripheral blood film and autoimmune screen.
a.
Clinical
ITP can be defined as isolated thrombocytopenia with no clinically apparent
associated conditions or other causes of thrombocytopenia (e.g. HIV
1
infection, systemic lupus erythematosus, lymphoproliferative disorders,
myelodysplasia, drug-induced thrombocytopenia, congenital/hereditary nonimmune thrombocytopenia, or pregnancy) 5 Level 9.
Patients with isolated abnormalities on serologic tests (e.g. positive tests
for antinuclear or antiphospholipid antibodies) but without a clinically evident
disorder (e.g. systemic lupus erythematosus) are included within the
diagnosis of ITP 6 Level 8 ; 7 Level 8.
Patients with thrombocytopenia and an associated clinically apparent
autoimmune disease may have an illness comparable to ITP. Lists of
conditions which must be considered and excluded in the diagnostic
evaluation of a patient with suspected ITP are as in Table 1.
Table 1: Differential Diagnoses
Falsely low platelet count
In vitro platelet clumping caused by EDTA-dependent or colddependent agglutinins.
Common causes of thrombocytopenia
Pregnancy (gestational thrombocytopenia, preeclampsia)
Drug-induced thrombocytopenia (common drugs include heparin,
quinidine, quinine, and sulfonamides)
Viral infections, e.g. HIV, infectious mononucleosis, hepatitis
Hypersplenism due to liver disease
Other causes of thrombocytopenia that mimic ITP
Myelodysplasia
Congenital thrombocytopenia eg. Wiskott-Aldrich syndrome, von
Willebrand disease type 2B
Thrombotic thrombocytopenic purpura-Haemolytic uremic
syndrome
Chronic disseminated intravascular coagulation
Thrombocytopenia associated with other disorders
Autoimmune diseases eg. systemic lupus erythematosus
Lymphoproliferative disorders eg. chronic lymphocytic leukaemia,
non-Hodgkin’s lymphoma
Adopted with permission from George et al 1998.
2
b.
Laboratory
The finding of thrombocytopenia on a routine blood count may be the first
indication of immune thrombocytopenia.
Thrombocytopenia needs to be confirmed on peripheral blood film
examination to exclude pseudo-thrombocytopenia. Pseudo-thrombocytopenia
due to EDTA-dependent platelet agglutination is a cause of spuriously low
platelet count. This condition occurs in about 0.1% of adults, and is easily
confirmed by the finding of a normal platelet count using a sample taken in
citrate or heparin rather than EDTA anticoagulant 8 Level 9.
An autoimmune screen should be carried out to exclude other autoimmune
diseases which may be associated with thrombocytopenia, e.g. systemic
lupus erythematosus or antiphospholipid syndrome. HIV antibody testing
should also be done in patients with risk factors for HIV infection 5 Level 9.
If the history, physical examination, blood count and peripheral blood film
examination are compatible with a diagnosis of ITP and do not include
atypical findings, additional investigations such as bone marrow examination
and assays for platelet antibodies are not indicated 5 Level 9.
Recommendations: Indications for Bone Marrow Examination
- over 60 years of age
- prior to splenectomy
- presence of atypical features
- poor response to first line treatment (eg. prednisolone) 5 Level 9
(Grade C)
- relapsed ITP following complete remission 9 Level 8
(Grade C)
Assays for anti-platelet antibodies such as direct platelet
immunofluorescence test (PIFT) and assays for antibodies to specific
platelet membrane glycoproteins (GP) IIb/IIIa and Ib/IX are not sensitive or
specific enough to be recommended as routine tests in the diagnosis of
ITP 10 Level 8 ; 11 Level 8.
However, these tests may be useful in distinguishing between immune and
non-immune thrombocytopenia in complex cases such as combination of
bone marrow failure associated with immune-mediated thrombocytopenia,
3
ITP patients refractory to first and second line treatment, drug-dependent
immune thrombocytopenia, miscellaneous disorders (rare) e.g. monoclonal
gammopathies and acquired auto-antibody mediated thrombasthenia 5 Level 9.
2.3 Management of Chronic ITP
Most adults with ITP have a good outcome except for a small subset that
has severe symptomatic ITP. Eighty-five percent of patients who had platelet
>30x 109/L had long term mortality risk equal to the general population
even without treatment. Patients who suffered major bleeding during their
follow up had median platelet counts of 10x 109/L 12, Level 6.
These findings favour treating patients with platelet count <30x 109/L and/
or symptomatic ITP. This will reduce the risks of infection through
immunosuppression 12 level 6; 13 , Level 6 ; 14 , Level 8.
Recommendations : When to Treat
Patients with platelet counts exceeding 30 x 109/L require no treatment.
Treat when symptomatic or when platelet count < 30x109/L unless
they are undergoing surgical procedures
(Grade C)
‘Safe’ Platelet Thresholds for Procedures
Platelet counts considered “safe” in adults undergoing procedures :
Dentistry > 10 x 109/L
Extractions > 30 x 109/L
Regional dental block > 30 x 109/L
Minor surgery > 50 x 109/L
Major surgery > 80 x 109/L
(Grade C)
a.
First Line Treatment
i.
Corticosteroid
Two thirds of patients will respond to prednisolone at 1mg/kg body weight/
day for 2-4 weeks 15 Level 9; 16 Level 8. However long term remission is seen only
in 10-20% of patients 16 Level 6; 17 Level 8.
The response to oral steroids is slower compared to intravenous
methylprednisolone 18 Level 3.
4
ii.
Intravenous Immunoglobulin (IVIG)
IVIG is effective in elevating the platelet count in 75% of patients, of whom
50% will achieve normal platelet counts. However the responses are
transient lasting between 3 to 4 weeks 19, Level 9. Combination of IVIG/ oral
prednisolone seemed to be more effective than IV methylprednisolone/ oral
prednisolone in adults with severe ITP 20, Level 2. There is no difference
between the two dosing of IVIG 0.4g /kg/day for 5 days and 1 g/kg/day for
two days 21, Level 2.
Adverse effects with intravenous immunoglobulin are common but generally
mild including fever, chills, rigors, headache and backache 20, Level 2.
Recommendations : First Line Therapy in Adults
Oral corticosteroids are used as first line therapy at 1 mg/kg body
weight /day (max 60 mg) for 2-4 weeks tapering off over several weeks
(Grade B).
Intravenous methylprednisolone (30 mg/kg body weight/day with total
maximum daily dose of 1 gram for 3 days) is an alternative to oral
prednisolone where more rapid response is required
(Grade B).
Intravenous immunoglobulin (1g/ kg body weight /day for 2 days or
0.4 g/kg/day for 5 days) is useful in severe ITP who require rapid rise
of platelet count.
(Grade A)
b.
Second Line Treatment
i.
Splenectomy
Splenectomy is considered as second line therapy with two thirds of patients
achieving a complete remission 22 Level 8; 16 Level 8; 23 Level 8; 24 Level 8; 25 Level 8; 5 Level 9; 26
Level 9
. The rest will experience a lesser increase or only transient
normalization of platelet counts. Most relapses occur within the first 6 months
after splenectomy, however, a small percentage of patients continue to
relapse thereafter 16 Level 8; 27 Level 8.
5
Predicting response to splenectomy
There are conflicting data on the predictive value of the response to steroids
28 Level 8; 29 Level 8; 30 Level 8; 31 Level 8; 32 Level 8; 23 Level 8
and IVIG 33 Level 8; 34 Level 8; 30 Level 8; 29
Level 8; 35 Level 8; 23 Level 8; 32 Level 8
on splenectomy but in general they do not have
a high predictive value.
The most sensitive indicator of response to splenectomy is the indiumlabelled autologous platelet scanning with more than 90% response if
platelet destruction is primarily in the spleen 36 Level 8. However, platelet
sequestration studies are difficult to perform and currently not available in
Malaysia.
The timing of splenectomy does not appear to affect the response rate
.
22
Level 8; 36 Level 8; 30 Level 8; 31 Level 8; 23 Level 8; 32 Level 8
Post-operative complications
Splenectomized patients have a small risk for overwhelming sepsis with an
estimated mortality rate of 1.2% 37 Level 1.
Operative mortality rates are < 2 % in most series 38 Level 8; 12 Level 8; 24 Level 8.
Recommendations : Prevention of Post Splenectomy Sepsis
At least 2 weeks before surgery, the patient should be immunized with a
polyvalent pneumococcal vaccine, Hemophilus influenzae b (Hib)
conjugate vaccine and meningococcal polysaccharide vaccine. (Grade B)
A booster dose of pneumococcal vaccine should be given every 5
years.
(Grade B)
Prophylactic antibiotics with oral penicillin 250 mg bd or erythromycin
500 mg bd should be given.
(Grade C)
The optimal duration of antibiotic prophylaxis is still uncertain (Grade
C) but is recommended lifelong in the UK guidelines.
(Grade C )
Accessory spleen
The presence of an accessory spleen should be considered in patients
who fail to respond to splenectomy or relapse following an initial response.
6
ii.
Danazol
Response can be as high as 60% especially in older females and those who
have undergone splenectomy 39 Level 5. It is used as a steroid-sparing agent in
steroid responsive patients who require longer term high dose steroids or in
patients who are refractory to steroids. The usual dose is 200 mg 2-4 times
daily 39 Level 5 and a trial of at least 6 months should be allowed.
iii.
Azathioprine
Approximately 20% of patients may achieve a sustained complete response
with this agent while 30 to 40% may have a partial response 40 Level 9. The
recommended dose for ITP is 2 mg/kg/day usually up to a maximum of
150mg/day 26 Level 9. The treatment should be continued for up to 4 to 6
months before a patient is considered non-responsive 41 Level 8; 42 Level 8.
Azathioprine is associated with few side effects, even with prolonged use 43
. The potential side effects include a reversible leucopenia and
elevated transaminases. Secondary malignancies and myelodysplastic
syndrome have been reported 44 Level 9.
Level 9; 41 Level 8
iv.
Dapsone
Responses are seen in 50% of patient with platelet counts < 50 x109/L with
sustained responses in 25% of patients. Half of all patients with chronic
ITP treated with dapsone will show some response within 3 weeks 45 Level 3.
It is less effective in severe cases especially those who have undergone
splenectomy 46 Level 4. The usual dose is 75-100 mg orally 45 Level 3.
v.
Anti-D
This is effective only in Rh(D) positive non-splenectomized patients with
response rate of up to 75 to 90% of adults with ITP. The effect last for more
than 3 weeks in 50% of responders 47 Level 8. The usual dose is 50-75mcg/
kg 48 Level 8; 47 Level 8; 49 Level 8. However this drug is not readily available in Malaysia.
Recommendations : Second Line Therapy in Adults
Patients not responding to steroids or requiring persistently high doses
require second line therapy. The choice of therapy must be
individualized. The treatment options are:
- Splenectomy.
- Danazol
- Azathioprine
- Dapsone
- Anti-D
Grade C
7
c.
Refractory ITP
Refractory ITP is defined as failure to respond to first or second line treatment.
This group accounts for 5.6% of all patients with ITP and are expected to
have the worst outcome with a 4.2 fold increased mortality risk 12 Level 6.
The cornerstone of management is to raise the platelet counts to a safe
level of more than 30 X 109/L taking into account coexisting risk factors for
bleeding, patient’s level of acceptance of modifications in lifestyle, tolerance
or lack of tolerance to treatment, and the potential toxic effects of each
intervention 12 Level 6. Elderly patients are both more likely to have severe
bleeding and to suffer debilitating side effects from treatment 50 Level 3.
Treatment Options
i.
Eradication of Helicobacter Pylori
The regression of ITP has been reported after eradication of Helicobacter
pylori 51 Level 5.
ii.
Intravenous Immunoglobulin (IVIG)
Repeated infusions of IVIG are reserved for intervention during serious
bleeding and to raise platelet count before surgical procedure. It is often
lifesaving, but refractoriness can develop 12 Level 6.
iii.
Vinca Alkaloids
The overall response is 50% in splenectomized patients, but is usually not
sustained 52 Level 8. It may cause a transient increase in the platelet count
lasting between 1 and 3 weeks in two-thirds of patients treated. The dose
for vincristine is 1 mg (occasionally 2 mg) or vinblastine 5-10 mg weekly
for 4-6 weeks.
iv.
High Dose Methylprednisolone
Two studies have shown that high dose methylprednisolone is effective in
the treatment of patients with refractory ITP 53 Level 9; 18 Level 3.
v.
Cyclosporin A
Cyclosporin A can be used as monotherapy or in combination with steroids.
Two small case series reported responses between 50-80% 54 level 8; 55 Level 8.
The cyclosporin dose is between 2.5 to 5 mg/kg/day in divided doses. The
patient should be treated for at least 4 weeks before a response can be
observed. The side effects may limit widespread practical use.
8
vi.
Mycophenolate Mofetil
Mycophenolate mofetil had been shown to be of value in some patients
with autoimmune cytopenias including refractory ITP 56 Level 8; 57 Level 5 with
overall response of 62%. The dose is 1.5 to 2.0 g/day. Side effects are
quite tolerable with slight nausea and diarrhoea.
vii. Anti-CD20 Antibody (Rituximab)
The overall response rate is reported between 40 to 50%. Younger patient
have a better response 58 Level 8. Twenty eight percent of patients will have
sustained response more than 6 months. The recommended dose is
375 mg/m2 rituximab weekly for 4 weeks 58 Level 8; 59 Level 8.
viii. Combination chemotherapy
Combination chemotherapy including cyclophosphamide, vincristine with
prednisone has been reported to give a response of 80% with prolonged
sustained effect 60 level 5. The side effects include myelosuppression and risk
of secondary malignancies, and hence should be used with caution.
ix.
Others
Other modalities for treatment include liposomal doxorubicin 61 Level 8 anti
CD52 (Campath-1H) 62 Level 5 and protein A immunoadsorption 63 Level 5. Bone
marrow transplant should only be considered in the experimental context
until there is a bigger clinical trial to prove its efficacy 64 Level 9; 65 Level 9.
Recommendations : Management of Refractory ITP in Adults
For patients who have platelet counts between 10 to 30 X 109 /L (Grade
B) without other risk factors for bleeding, treatment is not indicated
unless surgery is planned.
(Grade C)
Modalities of treatment include eradication of Helicobacter Pylori,
Intravenous Immunoglobulin (IVIG), high dose methylprednisolone,
cyclosporin A, mycophenolate mofetil, rituximab, and combination
chemotherapy.
(Grade C)
d.
Emergency Treatment
There is no published data on the efficacy of different treatments for the
management of urgent, life-threatening bleeding. The serious consequences
of severe, life-threatening bleeding justify the use of several regimens.
9
Appropriate interventions include platelet transfusions, high-dose parenteral
glucocorticoid (e.g. methylprednisolone 30 mg/kg daily for 3 days), and
IVIG, either alone or in combination with corticosteroids 26 Level 9.
Conditions requiring urgent treatment in adults with ITP are:
1.
2.
3.
active bleeding from the gastrointestinal or genitourinary tracts
intracranial bleed
bleeding into important structures e.g. upper airway
The aims of treatment are to elevate platelet count quickly (within 24 hours)
and to arrest bleeding.
Recommendations : Emergency treatment
1. i.v. methylprednisolone 500mg to 1g/day for 3 days
2. IVIG 1g/kg/day for 2 consecutive days
3. Platelet transfusion
Emergency splenectomy is considered if above measures fail to
increase platelet count to safe level i.e. above 50x109/L. (Grade C)
Indications for platelet transfusion in ITP
Platelet transfusion in ITP is only given in the following situations:
1.
life-threatening haemorrhage e.g. intracerebral haemorrhage (ICH)
2.
severe thrombocytopenia < 10 x 109/L and patient has to undergo an
emergency surgery
High dose i.v. steroids and IVIG must also be given together to raise the
platelet counts and to stop the haemorrhage. Platelet survival is increased
if the platelets are transfused immediately after IVIG infusion 66 Level 9.
Recommendations : Platelet Transfusion Dosage
• 6-8 U of platelet concentrate, or 1 U/10 kg body weight. (Grade C)
1 U of platelets to increase count of a 70-kg adult by 5-10 x 109/L
and an 18-kg child by 20 x 109/L
(Grade C)
10
3.
ITP IN CHILDREN
In children, ITP is usually an acute, self-limiting disorder that resolves
spontaneously. The clinical onset is usually acute, with a spectrum of
bleeding severity ranging from superficial (petechiae, purpura) to lifethreatening. Hepatosplenomegaly or lymphadenopathy is absent. The
majority will give a history of a viral infection in the preceding 2-4 weeks.
75% of patients remit spontaneously with 70% achieving platelet count of
more than 50 x109/L by the fourth week of illness 67 Level 9.
The diagnosis can be made clinically based principally on the history,
physical examination (no stigmata of malignant disease or congenital
thrombocytopenia), full blood count (isolated thrombocytopenia), and
examination of the peripheral blood smear (exclude abnormal cells).
Bone marrow examination is seldom required. Less than 4% of 127 children
had a different diagnosis from ITP following bone marrow examination 68
Level 8
. It is only indicated if the patient is not responding to therapy or before
starting steroids (to avoid partially treating an undiagnosed acute leukaemia)
26 Level 9
.
The need for other investigations depends on clinical indications : ANF
and DNA antibodies in those progressing into chronic ITP, CMV serology in
those under 1 year of age, immunoglobulin levels in those with recurrent
infections and HIV screening for those at risk e.g. parents with HIV infection,
intravenous drug users. Coagulation profile is needed for those with
suspected non-accidental injury, inherited bleeding disorders or
meningococcal infection.
Recommendations : Diagnosis of ITP in Children
Full blood count with differential and a peripheral blood film
examination are the only two recommended laboratory investigations
in a child with typical clinical features of ITP
(Grade C)
Bone marrow examination is only indicated in patients not responding
to therapy or before starting steroids. Additional investigations are
done as clinically indicated
(Grade C)
11
3.1
Management of Acute ITP
Outpatient observation and monitoring will suffice for those with platelet count > 20
x109/L without bleeding tendencies. Precaution with physical activities, avoidance
of contact sports and seeking immediate medical attention if bleeding occurs should
be advised 69 Level 9. A repeat platelet count should be performed within the first 7-10
days to ensure there is no evidence of a serious evolving marrow condition.
Otherwise, the count can be repeated only when clinically indicated 69 Level 9.
Hospitalisation is required in acute severe life-threatening or mucosal bleeds
regardless of platelet count or if platelet count is < 20 x109/L without bleeding
but with poor access to health care. Hospital admission also depends on
parents’ request and on their confidence in homecare 70 Level 9.
Treatment is indicated if there is a life threatening bleeding episode (e.g.
ICH) regardless of platelet count or if the platelet count is < 20 x109/L with
mucosal bleeding 5 Level 1.
There is insufficient evidence to guide treatment in those with platelet count of
<10 x109/L without bleeding manifestations. Treatment should be individualized.
The choice of treatment is : IVIG 0.8 g/kg as a single dose 71 Level 1 or oral
steroids (oral prednisolone 2 mg/kg/day for not more than 14 days or oral
prednisolone 4 mg/kg/day for 4 days) 72 Level 6.
Both steroids and IVIG may shorten the thrombocytopenic phase in
responsive cases but do not influence outcome of disease. They are both
effective in raising platelet count more rapidly compared to no treatment 73
Level 1
. However, there is no direct evidence indicating either treatment is
superior to the other, reduces bleeding complications or mortality from ITP
or influences progression to chronic ITP 74 Level 9; 26 Level 9; 2 Level 8.
Recommendations : Management of Acute ITP in Children
Hospitalisation is required in acute severe life-threatening or mucosal
bleeds regardless of platelet count or if platelet count is < 20 x109/L
without bleeding but with poor access to health care.
(Grade C)
Management of ITP should not depend only on platelet numbers but
also on clinical severity. IVIG and oral steroids are the recommended
choices of treatment but they do not influence the final outcome of
the disease.
(Grade A)
12
Treatment options include :
IVIG 0.8 g/kg as a single dose, or
oral prednisolone 2 mg/kg/day for not more than 14 days, or
oral prednisolone 4 mg/kg/day for 4 days
3.2
Management of Chronic ITP
Chronic ITP in children is defined as persistent thrombocytopenia after 6
months of onset, is strikingly different from that in adults with complete,
spontaneous remission seen in the majority 75 Level 6; 76 Level 6. There is a wide
spectrum of manifestations. However, there is insufficient evidence in the
literature to determine the best management for these patients 77 Level 9.
As far as possible, allow the disease to remit spontaneously. However, other
causes of thrombocytopenia e.g. SLE should be considered. Asymptomatic
patients can be left without therapy with advice regarding precautions during
physical activities, contact sports, dental/surgical procedures and menses.
Symptomatic children may need short courses of treatment (as for acute
ITP) during periods of “relapse” or for surgical procedures. Prolonged steroid
therapy or regular infusions of IVIG are not justified 75 Level 6.
For those with persistent bleeding problems, second-line therapies include
steroids e.g. dexamethasone (oral 1mg/kg) given on 4 consecutive days
every 4 weeks for 4 months 78 Level 8 or oral methylprednisolone for 7 days
(30 mg/kg for 3 days followed by 20 mg/kg for 4 days) every 4 weeks for
maximum of 6 courses 79 Level 8 and anti-D immunoglobulin 45-50 ug/kg
immunoglobulin in Rh positive patients 80 Level 6. Second-line therapy should
only be started following consultation with a paediatric haematologist.
Recommendations : Management of Chronic ITP in Children
Allow chronic ITP children to remit spontaneously as far as possible
(Grade B)
Use of steroids or IVIG should be for acute bleeding manifestations
only (Grade B)A paediatric haematologist should be consulted if
second-line therapy is required
(Grade C)
13
3.3 Refractory ITP
Splenectomy is rarely indicated in children with ITP as spontaneous
remissions continue to occur up to 15 years from diagnosis 75 Level 6. It is
important to note that the risk of dying from childhood ITP is very low
(0.002%) whilst the mortality associated with post-splenectomy sepsis is
1.4 – 2.7% 36 Level 8; 81 Level 8.
However, splenectomy is justified when there is a life threatening bleeding
event or severe lifestyle restrictions and where there has been no or only
transient success with intermittent IVIG, pulsed steroids or anti-D 82 Level 9.
Up to 70% of children achieve complete remission post-splenectomy 83 Level 6.
It is important to ensure pre-splenectomy immunization against
pneumococcus, haemophilus and meningococcus . Post-splenectomy
patients require life-long penicillin prophylaxis and 5-yearly pneumococcal
booster (CDC 1993).
Agents that have been used when first and second-line therapies fail include
Rituximab 84 Level 8 and cyclosporin 54 Level 8. Children who reach this stage
should be managed by a paediatric haematologist.
Recommendation : Management of Refractory ITP in Children
In children with symptomatic refractory ITP, splenectomy is an option.
There is insufficient evidence to recommend third-line
immunomodulating agents
(Grade C)
3.4
Emergency Treatment
Serious bleeding e.g. severe epistaxis, GIT bleeding or bleeding causing a
drop in haemoglobin concentration was seen in 17% of 332 pts over 10
years 85 Level 9. However, the most serious form of bleeding i.e. intracranial
bleeding has a very low incidence of 0.1 to 0.5 % 86 Level 8 ; 87 Level 8 ; 88 Level 8.
The following methods have been employed in cases of serious bleeding /
intracranial haemorrhage :
Platelet transfusion
A rapid increase in the platelet count is necessary in life-threatening
haemorrhage. The immediate administration of a larger than usual (8-12
14
units per sq meter) transfusion of donor platelets plus i.v.
methylprednisolone 30 mg/kg (maximum 1 gm) over 20 to 30 minutes have
been advocated 89 Level 6; 4 Level 6.
Intravenous methylprednisolone
The usual dose used is 30 mg/kg/day for three days. Seventy percent of
children have been reported to show an unsustained rise in platelet counts
90 Level 8; 91 Level 8; 92 Level 8
.
Intravenous immunoglobulins (IVIG)
Infusion of IVIG has been reported to cause a rapid rise in platelet count to
at least above 30 x109/L in 80% of children. A single dose of 0.8 g/kg or 1
g/kg 71 Level 8 has been shown to be as effective as doses of 0.25 – 0.5 g/kg/
day for two days in a randomized multicentre study 93 Level 5.
Combination IVIG and methylprednisolone
Several authors have combined IVIG with methylprednisolone to increase
the platelet count rapidly in life-threatening bleeds 94 Level 8 reported 11of 11
patients had increased platelet count above 40 x109/L following infusion of
IVIG plus methyl-prednisolone and this was sustained for at least 24 hours
(Level 8). In a consensus statement, 5 Level 9 also reported on the efficacy of
this combination.
Emergency splenectomy
This measure will lead to a rapid increase in platelet count; at least 75% of
patients will respond 95 Level 9 ; 96Level 8. If this procedure is to be performed, the
laparoscopic method is preferred. Laparoscopic splenectomy has been
associated with a shorter hospital stay, diminished blood loss and lower
cost compared to an open procedure 97 Level 9 ; 98 Level 9.
Recommendations : Emergency Treatment
In the event of life-threatening haemorrhage, a two-to-three fold
transfusion of donor platelets is required.
(Grade C)
Concomitant use of IVIG alone (0.8 g/kg stat) or in combination with
methylprednisolone (30mg/kg/day; max 1 gm for three days) is
recommended. Emergency splenectomy (preferably laparoscopic)
may be justified.
(Grade C)
15
4.
ITP IN PREGNANCY
Thrombocytopenia in pregnancy is relatively common, occurring in 7 to 10% of
unselected pregnancies. However, ITP only accounts for approximately 3% of
these cases 99 Level 9 as compared to gestational or incidental thrombocytopaenia
of pregnancy (74%) and hypertensive disorders of pregnancy (21%) 100 level 6.
ITP in pregnancy must be differentiated from other causes of
thrombocytopenia.
Table 2 Differential Diagnoses
1.
Gestational or incidental thrombocytopaenia of pregnancy (mild
thrombocytopaenia >70 x 109/L occurring in late gestation)
2. Pre-eclampsia
3. HELLP syndrome
4. Thrombotic thrombocytopenic purpura (TTP)
5. Disseminated intravascular coagulation (DIC)
6. Antiphospholipid syndrome
7. Folate deficiency
8. Viral: Dengue, HIV, HCV
9. Drug-related
10. Spurious due to platelet clumping or macrothrombocytes
Modified from British Committee for Standards in Haematology General
Haematology Task Force (2003)
4.1
Diagnosis
a.
Clinical
The diagnosis of ITP in pregnancy remains one of exclusion as there is no
confirmatory laboratory test 101 Level 9. Therefore it is important to obtain a
detailed history and physical examination to exclude other secondary causes
and to assess the clinical severity of haemostatic defects 102 Level 9.
b.
Laboratory
The aim of investigation is to confirm thrombocytopenia and to exclude
secondary causes. If gestational thrombocytopenia is suspected, only regular
monitoring of platelet counts is required without further investigations 103 Level
9; 100 level 6
.
16
Recommendations : Investigations for Thrombocytopenia in
Pregnancy
The important investigations include :
1) Full blood count
2) Peripheral blood film: to exclude platelet clumping and red cell
fragmentation (in TTP, pre-eclampsia, HELLP or DIC)
3) Coagulation screen (PT, APTT, fibrinogen, D-dimer)
4) Liver function tests
5) HIV screening
6) ANA
7) Lupus anticoagulant/ anticardiolipin antibody
• for patients with past history of unexplained pregnancy losses/
(Grade C)
thrombosis 102 level 9
Bone marrow examination is unnecessary unless there is suspicion
of myelodysplastic syndrome, leukaemia or lymphoma 104 Level 9
(Grade C)
4.2
Management
Although pregnancy is not discouraged in woman with preexisting ITP,
maternal and foetal complications can occur. Close collaboration between
haematologist, obstetrician, neonatologist and anaesthetist is needed to
ensure a good pregnancy outcome 26 Level 9.
Platelet counts in women with ITP may decrease as pregnancy progresses
and need to be monitored closely as follows:
1st to 2nd trimester
3rd trimester
at term
:
:
:
monthly
2 weekly
weekly
The principal of management in ITP during pregnancy is to do least harm
to both the mother and the foetus. The decision to treat is based on
assessment of the risk of significant haemorrhage.
Corticosteroids are considered safe with regards to potential teratogenecity
and foetal toxicity as 90% of the administered dose is metabolized in the
placenta 105 Level 6.
17
Intravenous immunoglobulin is effective and safe for use in pregnancy. It’s
effect is transient and last for about a month 104 Level 9.
Splenectomy should be avoided if possible or should be deferred to the
second trimester to prevent miscarriage 26 Level 9.
Anti-D Immuneglobulin among Rh positive non-splenectomized women can
be considered as second line therapy 106 Level 9.
Androgen analogues such as danazol and all the other potential teratogenic
agents like cyclophosphamide or vinca alkaloids are strictly prohibited in
pregnant women.
Recommendations : Modalities of Treatment for ITP in Pregnancy
Corticosteroids and IVIG are effective and safe in pregnancy and are
used as first line therapy.
(Grade B)
Androgen analogs such as danazol and cytotoxic agents are
contraindicated in the treatment of ITP in pregnancy due to its
teratogenecity.
(Grade C)
Splenectomy is considered only if above measures fail to elevate the
platelet counts and patient has serious bleeding. This is best deferred
until the second trimester to prevent miscarriage.
(Grade C)
a.
Management before 36 weeks
Management can be divided into 3 groups based on clinical presentation
and platelet count.
1)
Asymptomatic patients with mild to moderate thrombocytopenia
(platelet count >20 x 109/L)
a.
No treatment is required
b.
To expect further drop of platelet during 3rd trimester
2)
Symptomatic patients or those with moderate to severe
thrombocytopenia (platelet count <20 x 109/L)
18
a.
Corticosteroid prednisolone 1mg/kg/day with rapid taper to keep
<30mg/day (safe from adverse foetal effects)
AND/ OR
b.
IVIG 1g/kg (according to pre-pregnant weight) every month
3)
Severe thrombocytopaenia (platelet count <10 x 109/L)
The approach in managing these groups of patients is to deliver the
minimum amount of therapy necessary.
a.
high dose corticosteroid (methylprednisolone/dexamethasone)
AND
b.
periodic high dose IVIG 1g/kg x 2 days
Splenectomy during 2nd trimester is considered if above measures fail to
elevate the platelet count.
Recommendations : When to treat?
• Platelet count < 20 x 109/L before 36 weeks
• Symptomatic bleeding at any trimester
• Platelet count < 30 x 109/L after 36 weeks
b.
(Grade C)
Management after 36 weeks
The mother should be assessed at 36 weeks by both the haematologist
and the obstetrician.
•
platelet count >30 x 109/L
safe for normal vaginal delivery in patients with otherwise normal
coagulation 108 Level 9
•
platelet count <30 x 109/L
admit for pulsed IVIG and close monitoring
The mode of delivery in a mother with ITP is based on obstetric indications
.
109 Level 9
Caesarian section is only for obstetric indications and the patient will require:
i.
iv corticosteroids if platelet count between 30-50 x 109/L
ii.
IVIG and iv corticosteroids if platelet count <30 x 109/L
iii.
IVIG and iv corticosteroids plus platelet transfusion if platelet count
<10 x 109/L
19
Recommendations : Mode of delivery
The mode of delivery in mothers with ITP is decided primarily by
obstetrical indications
(Grade C)
The use of vacuum extraction and complicated instrumental delivery
should be avoided if possible
(Grade C)
c.
Management in labour
Platelet count above 50 x 109/L is safe for caesarian section under general
anaesthesia but not epidural anaesthesia. Epidural anaesthesia is best
avoided because of the risk of epidural haematoma and cord compression.
However, patients who prefer epidural analgesia need to be admitted earlier
for IVIG infusion in order to raise the platelet counts to a safe level >80 x 109/L
104 Level 9
.
If platelet counts are less than 50 x 109/L and patient requires immediate
caesarian delivery, administer IVIG and methylprednisolone. Give platelet
transfusion just prior to surgery.
‘Safe’ Platelet Thresholds for delivery
• vaginal delivery:
> 30 x 109/L
• caesarean section:
> 50 x 109/L
• epidural anaesthesia: > 80 x 109/L
(Grade C)
20
5.
NEONATAL CARE
The overall incidence of thrombocytopenia in newborns born to mothers with
ITP is reported to vary from 14.3 to 37.5% 110 Level 8; 111 Level 8. Severe
thrombocytopenia (<50 X 109/l) occurs in 8.9 to 14.7% 48 Level 8; 112 Level 8. Bleeding
is fortunately a rare event 113 level 8 with overall incidence of intracranial
haemorrhage about 0 to 1.5% 48 Level 8.
Prediction of neonatal thrombocytopenia is difficult, and there is no relationship
with maternal platelet counts. Infants from splenectomized mothers were
more likely to have thrombocytopenia 110 Level 8; 113 Level 8 as were mothers who
had presence of circulating antiplatelet antibody 110 Level 8. Thrombocytopenia
is more likely if there is a previous sibling with thrombocytopenia 115 Level 8.
Cordocentesis and foetal scalp sampling to measure foetal platelet counts
carry more risks than potential benefits and are not recommended 26 Level 9.
The application of scalp electrodes for monitoring in labour should be avoided
26 Level 9
.
Cord blood platelet count should be done and the neonate with
thrombocytopenia should be monitored daily. The platelet counts reach a
nadir on days 2 to 5 116 Level 8.
Severe thrombocytopenia (<20 X 109/L) or clinical haemorrhage can be treated
with IVIG with good response in 75% of patients 117 Level 8. Life threatening
complications should be treated with immediate platelet transfusions and
IVIG 26 Level 9.
Recommendations : Management of Neonates Born to Mothers
with ITP
The neonatology team should be alerted prior to delivery.
(Grade C).
The cord blood platelet count should be done for newborns of mothers
with ITP. In those with low platelet counts, the count should be monitored
till after the nadir, which is usually from Day 2 to Day 5.
(Grade C)
Treatment is only required when there is clinical bleeding or when the
platelet count is < 20 x 109/L. The first line therapy is with IVIG (1 g/kg).
Newborns with life-threatening haemorrhage should receive concurrent
platelet transfusion.
(Grade C)
21
TREATMENT ALGORITHM : ITP IN ADULTS
Presentation
platelets < 30 x 109/L
Acute Hemorrhage
platelets 30 - 50 x
109/L
Prednisolone if
bleeding or no
treatment
Prednisolone (1 mg / kg /
day)
Methylprednisolone
(1g/day for 3 days)
IVIG (1g/kg/day for 2 –
3 days)
Platelet transfusion
platelets > 50 x 109/L
No treatment
Chronic Immune
Thrombocytopenic
Purpura
platelets 30 - 50 x 109/L
platelets < 30 x 109/L
No treatment but
Prednisolone if bleeding
Active Bleeding
No Active Bleeding
IVIG
Prednisolone
Azathioprine
Danazol
Dapsone
IVIG
i.v. anti-D
Medical
Therapy
Methylprednisolone
± Splenectomy
platelets ≥ 30 x 109/L
platelets < 30 x 109/L
Consider splenectomy or
other immunosuppression
Gradual discontinuation of therapy
plt < 30 x 109/L
Refractory immune
thrombocytopenic purpura
platelets ≥ 30 x 109/L
No treatment
Note: Consideration for treatment
Note : Consideration
treatment should
should take into
account forpatient’s
take into account patient’s lifestyle,
lifestyle, access
totoemergency
access
emergency healthhealth
services and
status status
services and educational
educational
platelets < 30 x 109/L
No bleeding
No treatment
Inhibitors of platelet clearance
Prednisolone
IV immunoglobulin
Vinca Alkaloids
Danazol
Bleeding
Medical therapy
Immunosuppressive drugs
Azathioprine
Cyclophosphamide
Cyclosporin
Mycophenolate mofetil
Others
Rituximab
H pylori eradication
Experimental agents
BMT
Campath
Modified 73 Level 1 with permission
22
TREATMENT ALGORITHM : ITP IN CHILDREN
ACUTE PRESENTATION
Bleeding
Yes
Serious, life-threatening
haemorrhage
No
mucosal bleed
only
platelets < 10x 109/L
platelets > 10x 109/L
No active
treatment
consider treatment under
appropriate conditions
Platelet transfusion
(2-3 fold of normal dose)
plus i.v methylprednisolone
or combined with IVIG
Emergency splenectomy
Prednisolone 2mg/kg/day for 2
weeks OR prednisolone 4mg/kg x
4 days or IVIG 0.8 gm/kg stat
CHRONIC ITP
Bleeding
Yes
Acute
As per acute ITP
No
Recurrent, trouble-some
Impedes lifestyle
Dental or
surgical procedure
Short-term coverage
as per acute ITP
Second-line therapies
pulse dexamethasone
pulse methylprednisolone
i
23
No treatment
TREATMENT ALGORITHM : ITP IN PREGNANCY
Platelet count at
diagnosis*
< 10 x 109/L
10 – 20 x 109/L
> 20 x 109/L
OR bleeding
•
•
•
AND asymptomatic
Prednisolone
1 mg/kg/d
with rapid
taper to
<30mg/d ±
IVIG
Methyprednisolone
(500mg if <50kg or
1g if >50kg BW
daily for 3 days)
IVIG
(1g/kg/day for 2 –
3 days)
± Platelet
transfusion
No response
No
treatment
Response
consider splenectomy
if severe bleeding
monitor **
(defer till second trimester if possible)
OR
i.v. methylprednisolone
and IVIG
reassess at 36 weeks
9
platelets >
– 30 x 10 /L
safe for spontaneous
vaginal delivery
Note:
* after exclusion of other
causes of thrombocytopenia
Note:
in *pregnancy
after exclusion of other causes of
** frequency
of visits
depends
thrombocytopenia
in pregnancy
frequency of and
visits depends
on gestation
on**gestation
severity
of
and severity of thrombocytopenia
thrombocytopenia
platelets < 30 x 109/L
admit for IVIG
and close monitoring
if caesarean section obstetrically indicated
platelet count
>50 x 109/L
safe for Caesarean Section
30-50 x 109/L
<30 x 109/L
iv corticosteroids
i.v. methylprednisolone
+
IVIG
24
<10 x 109/L
i.v. methylprednisolone
+
IVIG
+
platelet transfusion
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33
ACKNOWLEDGEMENTS
The committee of this guideline would like to express their gratitude and
appreciation to the following for their contribution:
Panel of external reviewers who reviewed the draft form.
Technical Advisory Committee for Clinical Practice Guidelines for their
valuable input and feedback.
CPG Secretariat, particularly Datin Dr Rugayah Bakri, Head of Health
Technology Assessment Unit, and Ms Hanita Muhsin, Nursing
Manager, Medical Development Division, Ministry of Health Malaysia.
DISCLOSURE STATEMENT
The panel members have no potential conflict of interest to disclose.
SOURCES OF FUNDING
The development of the CPG on Immune Thrombocytopenic Purpura was
supported financially in its entirety by the Ministry of Health Malaysia and
was developed without any involvement of the pharmaceutical industry.
34
LEVELS OF EVIDENCE SCALE
Level
Strength of
Evidence
1
Good
Meta-analysis of RCT, Systematic review
2
Good
Large sample RCT
3
Good to Fair
Small sample RCT
4
Good to Fair
Non-randomised controlled prospective trial
5
Fair
Non-randomised controlled prospective trial
with historical control
6
Fair
Cohort studies
7
Poor
Case-control studies
8
Poor
Non-controlled clinical series, descriptive
studies multi-centre
9
Poor
Expert committees, consensus, case reports
anecdotes
Study Design
Adapted from Catalonian Agency for Health Technology Assessment & Research,
(CAHTAR) Spain
GRADES OF RECOMMENDATIONS
A
At least one meta analysis, systematic review, or RCT, or evidence
rated as good and directly applicable to the target population
B
Evidence from well conducted clinical trials, directly applicable to
the target population, and demonstrating overall consistency of
results; or evidence extrapolated from meta analysis, systematic
review, or RCT
C
Evidence from expert committee reports, or opinions and /or
clinical experiences of respected authorities; indicates absence
of directly applicable clinical studies of good quality